Identifying malnutrition in emergency general surgery

Background and aims
Emergency general surgery (EGS) practice is high risk. As many as 40-60% of EGS patients are malnourished. The resultant post-operative catabolic stress means there is a frequent need for nutritional support. Identifying these patients is paramount to minimising this risk but specific guidelines for EGS are lacking. The failure to do so leads to an increased risk of patient and organisational costs. This thesis aimed to examine the similarities/ differences in how surgeons identify malnourished EGS patients in the UK, and understand why any differences exist.

Methods and results
A mixed methods approach was used consisting of five studies to explore this issue. Each of these components is summarised below:
• A systematic review of 31 studies described inconsistency in how malnutrition is defined in EGS research literature. Many nutritional screening tools, assessment tools and alternative makers of nutritional status are used. Body mass index and albumin are the main indicators.
• A national survey of 166 National Emergency Laparotomy Audit (NELA) Leads representing 117/167 (70.1%) of hospitals in England and Wales Leads described inconsistency in current practice in identifying malnutrition in NELA-eligible patients. Several clinical and organisational barriers exist. There was no correlation with hospital laparotomy volume.
• Semi-structured qualitative interviews with 18 consultants practising EGS revealed many barriers affect the approach surgeons use to determine malnutrition in EGS patients. This can impact clinical and operative decision making, which was influenced by hospital setting.
• A national survey of 148 general surgeons highlighted that irrespective of seniority and IF experience, surgeons recognise malnutrition is important and can affect patient outcomes. However, there was a lack of confidence in doing so and nutritional training was limited.
• A discrete choice experiment of 148 surgeons demonstrated six variables were independently associated with the decision to start nutritional support in EGS, but surgeon and IF experience were not. Days likely to be without oral intake influenced decision making most.

Conclusions
There is inconsistency in how surgeons identify malnourished EGS patients in research and clinical practice. This is influenced by institutional factors, and impacts decision making on timing of nutritional support and operative outcomes. Twenty-one key findings are highlighted.